The amount of information contained in a report will depend on the nature of the matter and the purpose for which the report is sought. In most instances, you will be asked a series of questions in the letter of instruction. It is important that you address each question fully, and in the order asked.
Usually a report should contain:
- the patient’s history & complaints
- your findings on clinical examination
- tests performed and the relevant outcomes
- treatment provided
- opinions as to prognosis
- referrals to other health professionals
The extent of a patient’s prior history to be detailed in a report is a matter of judgment and balance. Personal information not relevant to the issues involved in the matter for which a report has been requested, need not be included. Conversely matters relevant to the degree of injury (e.g. a previous injury to the same site) should be included.
Health professionals face time constraints and so it can often be difficult to extract an accurate history from a patient regarding precisely how the injury occurred.
You may not have a precise record of how the patient’s injury occurred, for example, whether he or she slipped or fell. In court proceedings, the issue of whether the patient slipped or fell may be fundamentally important. By contrast, this question may be of small relevance to a health professional treating the patient. Courts appreciate that health professionals are not retained to be historians and that a notation of a patient “falling” is not meant to be a definitive declaration of the mechanism of the injury. However in writing a report, some care should be taken in describing the history provided.
If your records do not contain comprehensive information about how the injury occurred, you can avoid these difficulties by beginning this section of your report with the phrase, “A history sufficient for the purposes of treatment only was obtained and the details noted as follows…..”.
Similarly, a health professional may not record all symptoms in the clinical notes. Some symptoms may be unimportant for the immediate treatment of the condition. Therefore, a specification of the symptoms in a medical report should not be represented as an exhaustive record. You may avoid triggering debate in court over the content of your report by prefacing your discussion, “Symptoms recorded at the time of attendance….”. By clarifying the scope of your report in this way it is more readily acceptable to both parties. The parties may then consent to the report being accepted without your attendance at court.
In a medical report, clinical findings should be set out as the noted observations made on the clinical examination. Courts understand that it is neither possible nor appropriate to note every clinical finding on examination. Obviously there is little purpose for a treating health professional to note all negative findings and trivial positive findings.
If called to court, you may avoid cross-examination on this issue simply by stating in the report that, “the significant clinical findings which were recorded on examination were…..”.
Although mention of tests and results is usually uncontroversial, comments such as “X-rays were unremarkable and within normal limits” are vague and therefore may promote argument. More helpful may be a direct recitation of x-ray or scan reports, stating whether you have read or viewed the reports and agree with them.
It is preferable to give opinions only where you are asked for them specifically. If you are asked for an opinion, it is important to determine that the opinion sought relates to a clinical issue, and one of which you could reasonably be expected to have knowledge.
In some cases you may be asked specifically to discuss the likely prognosis, assess the extent of the patient’s permanent disability, the level of impairment or whether the injury has stabilised. You also may be asked to express an opinion in your report about the cause of a condition, the patient’s capacity for employment or life expectancy.
Particular care should be taken when proffering a general, non-medical opinion. You should ensure that your answers are not based on assumed circumstances but are grounded on ascertained facts. For example, stating that a patient is “not fit for pre injury work duties” relies on an assumed knowledge of what those duties involve. A health professional will invariably be extensively questioned over this type of broad assertion. By contrast, a statement which accurately describes the person’s capacity, such as “Ms X is fit for work that does not involve lifting weights in excess of X kilograms”, will avoid this problem.
Care should also be taken when making statements that involve a value judgment about a patient’s conduct. Statements to the effect that a patient is “genuine” or “malingering” are undesirable in reports. Impressionistic assessments may be used by one of the parties in the dispute to suggest a lack of objectivity in the writer. Objections to reports which appear biased may necessitate calling the health professional to give evidence in court. Assertions such as “liability should/should not be accepted by the insurer” should never be made in a report.
If you are asked to make an impairment assessment pursuant to the American Medical Association Guides to the Evaluation of Permanent Impairment, you should decline to do so unless you are competent to do so. Some jurisdictions do not accept such assessments unless the health professional has been accredited to provide such an assessment.